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External Evaluation for SiB/CBM project
Childhood blindness in Latin America: planning and implementing
programs for the prevention of blindness in children due to
retinopathy of prematurity
Evaluation of ROP programs in Rio De Janeiro, Brazil
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CONTENT
Part A: Background information 3
Terms of reference 3
Part B: Executive summary 4
Part C: Approach and methodology 6
Part D: Main findings 7
Increasing the coverage of effective programs: 9
Management Information system for ROP 12
National and regional workshops 12
Third regional ROP workshop 12
Educational materials for neonatal care and the prevention of ROP 13
Lessons learned 15
Best practices 16
Recommendations 17
Part E: Context analysis 18
APPENDICES 1. Map of Project area 22
2. Monitoring ROP programs 23
3. Workshop undertaken during project period 29
4. Agenda for regional ROP workshop and SIBEN meeting in
Cartegena, Colombia 30
5. Elearning resource for ROP 34
6. Program management 40
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Part A: Background information
1. Organization and project
Name of project organization: CBM
Name and title of responsible person: Andrea Zin
Title of project Retinopathy of prematurity in Brazil and Peru
Key project partners Instituto Catarata Infantil, PAHO/WHO collaborating
centre for childhood blindness prevention, Instituto
Fernandes Figueira - FIOCRUZ;
State Secretary of Health (State Government of Rio de
Janeiro)
Municipal Secretary of Health (Rio de Janeiro City Hall);
Telemedicine Department of University of Sâo Paulo
Date field activities started: January 2010
2. Evaluator
ROP programs in Rio de Janeiro, Brazil
Name of evaluator(s)
Clare Gilbert
Affiliation of evaluator:
London School of Hygiene & Tropical Medicine
Contact information +44 207 958 8332
Terms of reference (TOR):
The following outputs are included in the evaluation of ROP programs in Rio:
1. Increasing the coverage of effective programs for detecting and treating ROP, with establishment of
programs beyond the city of Rio
2. Management Information system for ROP developed and implemented
3. National and regional workshops held to disseminate best practice and for planning and improving
programs in Latin America, and countries in the region visited
4. Development of educational materials on best practices of neonatal care and for the prevention and
detection and treatment of ROP for neonatal intensive care personnel
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Part B: Executive summary
Provide a brief description of the project, its overlying objectives, and targeted beneficiaries.
Aim of project:
To decrease ROP as a cause of blindness in children in Peru and Brazil with emphasis on Lima and
Rio de Janeiro; to demonstrate scalable models which could be adapted for use in other countries of
the region and to develop low vision services in both countries, which could be adapted for use in
other countries of the region.
Objectives:
1. Improve neonatal care in Lima and Rio de Janeiro, using the lessons learnt from the current projects
in Lima and Rio de Janeiro, Brazil, and materials that have been or will be developed
2. Increase coverage of effective programmes for detecting and treating ROP in Lima and Rio de
Janeiro for neonatal units where programmes are not already in place
3. Develop hands-on training programmes for ophthalmologists and neonatologists outside Rio de
Janeiro and Lima so that programmes can be established beyond these two cities
4. Develop and implement a management information system to monitor activities
5. Establish low vision clinical training centre in São Paulo (Federal University of São Paulo) and Lima.
6. Establish low vision centres in Peru and Brazil
7. Increase awareness among health care personnel (nurses, neonatologists and ophthalmologists)
8. Expand the lessons learned from this project to other countries in the region through visits
(Guatemala, Honduras and El Salvador), national workshops (Brazil, Colombia, Guatemala,
Venezuela and Mexico), 2 regional ROP workshops (Nicaragua, Peru) and 1 regional low vision
workshop (Paraguay).
The ultimate beneficiaries are preterm infants at risk of visual loss from retinopathy of prematurity..
Key findings
With regard to topic relevance: The project addresses a topic of great relevance to Brazil and Peru, as
well as Latin America, where ROP is often the commonest cause of avoidable blindness. Control of ROP
blindness is a priority of the Pan American Health Organization for Latin America and the Caribbean.
With regard to project relevance: The approach adopted was highly relevant, entailing primary
prevention of ROP through training neonatologists and nurses to improve neonatal care; secondary
prevention, by increasing ROP programmes for detection and treatment of infants with the severe stages
of ROP, and tertiary prevention, by building the capacity of low vision services to improve visual function,
including children with irreversible visual loss from ROP.
With regard to capacity building: The main focus of each component of the project was capacity building,
through improving knowledge as well as skills of neonatologists and nurses, ophthalmologists and low
vision therapists. Essential equipment was also provided.
With regard to miscellaneous criteria: Sustainability was a key finding as the ROP programmes are fully
integrated into government health systems. The State sector did not have programmes and considerable
advocacy was required, but this was highly successful, leading to creation of new posts in maternity
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hospitals for ophthalmologists who were selected and appointed by the State Ministry. The programme
is not, therefore, dependent on the commitment and energy of a few ophthalmologists, but has the
potential to be ongoing and hence sustainable as well as to expand to other units.
Lessons learned
What are the most important lessons learned (not more than 5) for future activities?
1. Advocacy with the State Ministry of Health, which led to ROP programs being fully integrated and
sustainable.
2. Excellent clinical training and support: high quality ROP programs require motivated and committed
ophthalmologists who have had hands-on practical clinical training by ophthalmologists experienced
in examining and treating ROP. They also need to be trained in how to set up, run and manage a
program, as in this project. The ongoing support, supervision, mentoring and problem solving by the
trainers in this project is a model of best practice, maintaining quality as well commitment.
3. Health management information systems for ROP that are integrated into government systems are
likely to be used more regularly and have more an impact than stand alone monitoring systems.
4. National and regional multi-disciplinary workshops provide a mechanism for advocacy, planning,
networking, team building, sharing knowledge and problem solving. Other regions would benefit
enormously from the experiences in Latin America, where Andrea Zin has played a very major role,
supported by regional and international facilitators and experts.
5. The online educational materials provide a means of reaching large audiences at little cost to users.
Specific recommendations
What recommendations would you make for the project (not more than 5) to optimize future activities?
ROP programs:
1. An on-line library of images of ROP and its treatment would provide a useful resource during and
after training and to create awareness amongst other staff and parents.
2. A network of the ophthalmologists be developed using social media (e.g. Facebook) to provide a
mechanism for sharing experiences and knowledge, to discuss new developments in diagnosis
and treatment; to design and undertake simple research studies and to disseminate relevant
publications for discussion.
3. Monitoring of the ROP programs could be improved, and standard data forms and registers
would assist in this. Monitoring should include coverage, the number of infants examined and
treated, by birthweight group, follow up rates, and rates of regression after treatment.
4. Awareness of the risk and consequences of ROP needs to be raised amongst parents. State and
Municipal health systems need to work with neonatologists, nurses and ophthalmologists to
improve communication with parents. Neonatologists should take the responsibility for
communicating to parents/carers at discharge if the child needs follow up eye examinations.
5. Advocacy with the State Ministry of Health is needed to improve the long term follow up of
preterm infants to detect and manage other ocular morbidity associated with preterm birth and
ROP (i.e. high myopia and other refractive errors, strabismus, cortical visual impairment). The
State system provides this service but not the Municipal system.
6. Educational materials:
The online course should be translated into Spanish, for use other countries in Latin America,
and English, for other regions (with translation, as required).
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Part C: Approach and methodology
What approach was used for the evaluation (desk review, site visit, etc.)?
Site visit
At what project stage the evaluation was conducted?
End of project evaluation.
Who among the project partners and beneficiaries was contacted for the review?
Representatives of the State Ministry of Health
Representatives of the Municipal Ministry of Health
Instituto Fernandes Figueira-FIOCRUZ
What instruments were used to conduct the evaluation (questionnaires, interviews, discussions)?
Interviews and discussions:
Extensive discussions with Andrea Zin, the Project Manager;
Semi-structured and in-depth interviews with four of the six ophthalmologists who were trained to screen and treat ROP in the neonatal intensive care units (NICU) where they work;
Short meeting with ROP trainer, Dr Viviane Lanzelotte;
Informal discussion with neonatal nurses and neonatologists in the neonatal units visited;
Discussions with the Director of Health Services, Rio State, Dr Ana Neves;
Discussions with the Co-oridinator of Neonatal care, Municipal Health services, Dr Nicole Gianini;
Observation:
All four NICUs which have developed new ROP during this project were visited, as well as two NICUs in the Municipal system where the focus was on nurse training (one has a new ophthalmologist).
Review of documents and other materials:
Proposal and amendments; logframe
Ophthalmologist’s diaries and registers
Protocols
Data recording instruments
POINTS-ROP online educational materials
EpiMed State monitoring system
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Schedule of visits: I was accompanied by Dr Zin on all occasions.
Sept 2 Sept 3 Sept 4 Sept 5 Sept 6
NICU: Melquiades
Calazans; Babara
Gomet (O) and
neonatal staff
Hospital da Mulher
Heloneida Studart,
to see the new
NICU*
NICU: Albert
Schweitzer;
Renata Cabral (O)
and neonatal staff.
Reviewed Epi-Med
monitoring system
Meeting at IFF to
discuss current
research for
improving nutrition
in preterm infants.
Reviewed online
POINTS-ROP
course.
Co-ordinator of
neonatal care,
Municipal Health
services; Dr Nicole
Gianini.
Trainer in ROP: Dr
Viviane Lanzelotte
NICU: Fernando
Magalhães.
Leonardo Costa
(O)
NICU: Adão
Pereira Nunes;
Leonardo Costa
(O)
Director of State
Health Services;
Dr Ana Neves and
her team
O = ophthalmologist trained during SCB project; * not a project facility
Part D: Main findings
Does the project address an issue relevant for public health?
Yes. Retinopathy of prematurity is the commonest cause of avoidable blindness in many countries in
Latin America and also in Eastern Europe and SE Asia.
Is the project coherent with the Phase 4 of SiB strategy?
Yes. Priorities for Phase 4 were “to deliver comprehensive and sustainable eye-care services to people
living in neglected, marginalized urban areas”. The project was undertaken in urban populations in
Brazil, focusing on strengthening government services which are accessed by the poor (rather than the
NGO or private sectors), which promotes sustainability. The project was comprehensive, covering:
training neonatal staff in the prevention of ROP in preterm infants;
expanding programs for detecting and treating the serious stages of ROP;
providing low vision services for those with irreversible visual loss, including children with ROP.
This component of the project has been evaluated by Karin van Dyjk, a low vision expert;
instituting a health management information system for ROP;
conducting further national visits and workshops, and conducting one regional workshop
The focus of the different elements of the project in the neonatal care units in Rio are outlined in Table 1.
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Table 1. Neonatal care units included in the project in Rio, and main focus
Neonatal unit System Focus of SiB project Comment
Alexander Fleming M Neonatal care Already had an ROP program; Winding down pending closure
Oswaldo Nazareth M Neonatal care Already had an ROP program;
Closed in February 2013
Fernado Magalhaes M Neonatal care Already had an ROP program
Herculano Pinheiro M Neonatal care Already had an ROP program
Carmela Dutra 1 M Neonatal care; ROP S&T Needed a new ophthalmologist
Leila Diniz2 M Neonatal care; ROP S&T No ROP program before
Adao Pereira Nunes1 S Neonatal care; ROP S&T No ROP program before
Albert Schweitzer1 S Neonatal care; ROP S&T No ROP program before
Melquiades Calazans1 S Neonatal care; ROP S&T No ROP program before
Rocha Faria3 S Neonatal care; ROP S&T No ROP program before
Azevedo Lima3 S Neonatal care; ROP S&T No ROP program before
Araruama5 S Neonatal care; ROP S&T No ROP program before
Heloneida Studart4,5 S Neonatal care; ROP S&T Already had an ROP program M = Municipal health system S = State health system S&T= screening and treatment
1. NICUs visited and screening ophthalmologists met and interviewed 2. Covered by ophthalmologist who screens in Melquiades Calazans 3. Two ophthalmologists were trained for S&T for these units but they haven’t
started ROP programs (see below) 4. Covered by ophthalmologist coordinator of ROP program in Municipal
government. 5. Excluded from the project due to local administrative issues
A map of the project area is shown in Appendix 1.
Details of the total number of births in the maternity units associated with the neonatal units, and the
number weighing less than 1500g at birth and their survival rates are shown in Table 2. Neonatal units in
this project cover almost 25,000 live births. Survival rates of infants most at risk of ROP (i.e. those
<1500gs at birth) vary, ranging from 44% from 83%. The variability can have several causes, but there
are two main reasons: some units may admit sicker infants, and levels of neonatal care are likely to vary
in quality between units. In industrialized countries survival rates of infants <1500gs is around 90%.
As neonatal care improves it is anticipated that survival will also improve, particularly among those at
very high risk of ROP (i.e. <1000gs at birth). At the same time, bigger, more mature infants will be
exposed to fewer risk factors for ROP (e.g. infection, poorly administered and inadequately monitored
oxygen) and so ROP is likely to become less common in these larger babies.
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Table 2. Births in maternity units in the project, and survival of preterm infants most at risk of
retinopathy of prematurity
Births <1500g % N
Exisiting ROP Prog
IMMFM 3963 76 83% 59
HMCD 6120 91 71% 65
HMHP 3353 45 67% 30
HMAF 2619 53 58% 22
Subtotal 16055 265 68% 176
New ROP Prog
HMLD 5417 115 71% 82
HEAPN 2693 97 74% 72
HEMC 1753 43 60% 26
HEAS 4315 87 44% 38
Subtotal 8761 342 64% 218
ALL UNITS 24816 607 65% 394
In 2012 Survival <1500g
Population of preterm infants at risk
Are outputs satisfactory and robust as compared with international quality standards?
Increasing the coverage of effective programs:
The target was to expand ROP programs beyond Rio city, and eight NICUs (7 State, 1 Municipal)
were selected based on size, location, and willingness of Directors to develop a program. Two units in
the State sector withdrew for administrative reasons. The new ROP programs in four units cover a
further 30% of preterm births (60% are in the Municipal system which already had programs and 10%
are in private units). 341 babies have been examined in these new programs and 18 (5.3%) treated
(Table 3). Overall 1418 babies were examined in NIUCs where SiB has been supporting programs,
55 (3.9%) of whom were treated. Rates of ROP needing treatment varied from 1.9% to 12.2%,
reflecting varying case mix, levels of care and survival rates of infants most at risk.
The time period of this project is too short to be able to detect a decline in rates of ROP needing
treatment, but rates in existing ROP programs have declined over the last 10 years, when the overall
rate was 4.2% (Table 3).
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Table 3. rates of severe ROP that was treated in project neonatal units since 2010
Births <1500g % N Examined N % Examined N % Examined N % Examined N % Examined N %
Exisiting ROP Prog
IMMFM 3963 76 83% 59 96 4 4,2% 94 2 2,1% 97 5 5,2% 37 1 2,7% 324 12 3,7%
HMCD 6120 91 71% 65 95 3 3,2% 86 0 0,0% 109 2 1,8% 73 2 2,7% 363 7 1,9%
HMHP 3353 45 67% 30 28 1 3,6% 22 4 10,0% 30 3 10,0% 30 3 10,0% 110 11 10,0%
HMAF 2619 53 58% 22 132 3 2,3% 113 3 2,7% 63 2 3,2% 16 0 0,0% 324 8 2,5%
Subtotal 16055 265 68% 176 351 11 3,1% 315 9 2,9% 299 12 4,0% 156 6 3,8% 1121 38 3,4%
New ROP Prog
HMLD 5417 115 71% 82 55 3 5,5% 62 5 8,1% 57 1 1,8% 174 9 5,2%
HEAPN 2693 97 74% 72 13 1 7,7% 27 4 14,8% 37 1 2,7% 77 6 7,8%
HEMC 1753 43 60% 26 29 2 6,9% 20 1 5,0% 49 3 6,1%
HEAS 4315 87 44% 38 41 0 0 41 0 0,0%
Subtotal 8761 342 64% 218 68 4 5,9% 118 11 9,3% 155 3 1,9% 341 18 5,3%
ALL UNITS 24816 607 65% 394 383 13 3,4% 417 23 5,5% 311 9 2,9% 1462 56 3,8%
Treated Treated
ROP programme
2012
ROP programme
2011
ROP programme 2013
(to June)
In 2012
2010-June 2013
Survival <1500g
ROP programme
2010Population of preterm infants at risk
Programme not started Programme not started Programme not started
Treated Treated Treated
Programme not started
Programme not started
Programme not started Programme not started
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Another positive change over the last 10 years is that the birth weight (BW) and gestational age (GA)
of infants treated have also declined over time, suggesting that neonatal care has improved between
the earlier study in 2004-6 and June 2012, with bigger, more mature infants being at less risk than
previously. The median BW of treated babies was 850g (range 400-1670g) and the median
gestational age was 29 weeks (range 23-34), which is close to the values seen in industrialized
countries. As no infants were treated who had a gestational age of greater than 34 weeks,
consideration could be given to changing the screening criteria to ≤ 34 weeks (rather than the current
≤ 35 weeks) which would considerably reduce the number of babies to be examined.
Figure 1. Birth weight and gestational age of infants treated for severe ROP 2010-2013.
Black dotted lines = current screening criteria: Red dotted line, possible revised criteria for gestational age
The programs are of very high quality in terms of training, examination techniques and indications for
and methods of treatment (i.e. laser peripheral retinal ablation). The project ophthalmologists reported
high response rates to treatment, but this is not currently being monitored.
There is a new, highly controversial treatment for severe ROP which involves injecting an agent into
the back of the eye which blocks the growth of blood vessels (an anti-VEGF preparation). Avastin is
preparation most frequently used. Although Avastin reduces ROP there are concerns that this may
only give short term control of the disease, which can recur months later. It is known that the drug can
escape into the blood stream, and there are concerns that there may be unwanted complications in
other organs as they develop (e.g. in the brain, lungs and kidneys). Avastin is not available in the
government sector in Brazil so the issue of its use does not arise, but it is being used extensively in
other countries in the region, often without long term follow up, as it is quick and easy to administer.
All the ophthalmologists said they would consider using Avastin but just for the most difficult cases as
its safety profile is not yet known.
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It was not possible to assess the skills of the ophthalmologists but all have had excellent training, they
continue to be supported by the trainers and they work together very well as a team, for example, by
discussing difficult cases.
Management Information system for ROP developed and implemented:
Dr Andrea Zin and colleagues were finalizing a stand alone, on-line system for monitoring ROP
programs when it became clear that the State Ministry of Health were implementing an online system
called Epi-Med. This system was developed by a private company for monitoring intensive care
services, including neonatal care, in the State system. Dr Zin gave input to the development of Epi-
Med and so data on ROP are being routinely collected. The system is now being rolled out across the
State of Rio (population 16 million). Data on ROP is, therefore, now fully integrated into the State
monitoring system. The Municipal Health system, which covers the city of Rio (population 10 million)
are also considering establishing a monitoring system which would also include ROP.
One area that could be improved is in monitoring the coverage of the program (i.e. the proportion of
eligible babies who were actually examined), rates of completed examinations (i.e. babies are
examined until they are discharged from the ROP program) and the outcome of treatment. Data are
not being collected to allow assessment of coverage, except in one NICU, and review of the ROP
register of examined babies in two NICUs showed that 10% and 24% of babies had not attended for
all their examinations. Follow up after babies leave the NICU is a problem everywhere, and not
unique to Rio. The examining ophthalmologists were aware of the problem and had tried different
solutions e.g. calling mothers on their cell phones. A more systematic approach is needed, with
neonatologists and nurses being responsible for better communication with mothers, particularly at
the time of discharge if their infant requires further eye examinations. (See recommendations and
Appendix 2.)
National and regional workshops:
The target to conduct six workshops has been reached and two (target three) countries have been
visited (see Appendix 3). Over 300 professionals attended the workshops, with an almost equal mix of
ophthalmologists, neonatologists/pediatricians and nurses. International experts in ROP from Latin
America and beyond (ophthalmologists, neonatologists and a neonatal nurse) have facilitated the
majority of the workshops with Dr Zin.
Third regional ROP workshop
The third regional workshop was supported by the project. It took place in Cartagena, Colombia on
September 11-12th, and Clare Gilbert was one of the international facilitators. The meeting was
attended by 53 professionals (neonatologists, ophthalmologists, nurses) from 13 countries in Central
and South America (Argentina, Brazil, Bolivia, Colombia, Chile, Cuba, Dominican Republic, El
Salvador, Guatemala, Mexico, Nicaragua, Peru, Venezuela), Ministry of Health representatives from
Brazil, Colombia and Chile, ORBIS international (who also supported the meeting), Dr Juan Carlos
Silva, Director, Program for the Prevention of Blindness, PAHO, and the Dr Alejandro Vasquez de
Kartzow, President of the Pan American Association of Ophthalmologists. One Assistant Professor of
Pediatric Ophthalmology from Duke University and one ophthalmology resident from University of
Pennsylvania, USA, attended as observers. (See Appendix 4 for the agenda.)
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The main areas of focus during the workshop were as follows:
The importance of PAHO and government policies and support in developing ROP programs that
are integrated and sustainable;
Update of data from recent clinical trials on optimal oxygen levels to reduce severe ROP;
Discussion of the potential role of anti-VEGF preparations in the treatment of severe ROP;
The importance of data collection and monitoring ROP programs so they can be improved.
Information regarding whether Ministerial Resolutions and/or laws had been passed making eye
examination of preterm births mandatory, whether countries had develop their own guidelines, and
whether there were systems in pace for monitoring programs. The following were reported by the 13
countries represented:
Ministerial resolutions 6 Argentina, Chile, Colombia, El Salvador, Mexico and Peru
Law 6 Argentina, Chile, Colombia, El Salvador, Mexico and Peru
National guidelines 9 Argentina, Brazil, Chile, Colombia, El Salvador, Mexico, Nicaragua,
Peru and Venezuela
Monitoring system 4 Argentina, Brazil, Chile, Colombia and Venezuela
A positive development that emerged during the regional workshop is that planning, organizing and
management of ROP workshops in the region in the future will fall under the ROP Society of the
PanAmerican Association of Ophthalmologists. Membership of the ROP Society is international and
multidisciplinary, with several committees which each have clearly defined areas of activity (e.g.
education).
The output of the workshop included:
Updated regional guidelines in relation to the prevention of ROP through improving neonatal
care and for detecting and treating ROP;
Guidelines on monitoring ROP programs;
A document on the indications for treatment with anti-VEGF agents, a protocol and informed
consent form for parents (to be finalized after further consultation)
Priorities for action by each country;
Delineation of the roles and activities of the ROP Society of PAAO;
All these outputs (except for the anti-VEGF document) as well as pdfs of all the presentations given
during the meeting are available to all participants on DropBox.
The regional ROP workshop was followed by a seminar at the regional neonatology meeting, SIBEN, on
September 11th. The session was attended by about 200 neonatologists and nurses (Agenda Appendix
4).
Educational materials for neonatal care and the prevention of ROP:
The materials are based on an earlier study led by Andrea Zin which involved assessing the
effectiveness of training neonatal nurses. The training was called POINTS or Care, as it covered
control of Pain, Oxygen, Infection, and improving Nutrition, Temperature control and Supportive care.
Dr Zin has added control and treatment of ROP. The materials were developed collaboratively with
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Andrea Zin, Dr Cynthia Magluta, a public health physician at IFF, and Chao Lung Wen, Department of
Telemedicine, University of São Paulo. The content which includes text and DVDs, is all evidence
based, up to date and practical, and of exceptionally high quality in terms of the educational approach
and presentation. Almost 5,000 people have registered for the on-line, 8 module course which was
recently advertised.
Course link: http://neonatal.estacaodigitalsaude.org.br/aia/. Access is limited to those who have
registered. See Appendix 5 for screen-captures of some of the web pages.
Has/can the project lead to relevant policy changes?
Control of visual loss from ROP is already a policy of the Pan American Health Organization (PAHO) and
is a priority for Brazil. The State Ministry of Health has drafted a law, which is currently under review
which would make examination of all preterm infants mandatory. This is likely to have very positive
repercussions, leading to greater coverage of ROP programs.
In Rio considerable advocacy was required by Dr Zin to establish ROP programs in the State system.
This led to recruitment and employment of ophthalmologists who were subsequently trained in ROP by
Dr Zin and Dr Lanzelotte. This project has the potential for replication in other States in Brazil.
In the State health system, long term follow up of preterm infants is not adequate. Infants are referred to
general primary health care services, which are not adequately resourced to be able to detect and
manage the range of morbidities associated with preterm infants. This issue was raised with the Director
of the State Health Services who said that this would be addressed. The same applies to improving care
in the first “golden hour” after preterm birth, when gentle resuscitation and avoiding unnecessary oxygen
can have a major impact on the development of complications of preterm birth, including ROP. This
requires co-ordination between obstetricians, paediatricians and neonatologists.
How relevant are the findings for the regional/international community? Will findings advance the field?
Brazil ranked 10th in terms of the number of preterm births (WHO, Born Too Soon, 2012): controlling
blindness from ROP in Brazil, is therefore highly relevant (Table below).
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ROP programs:
In Brazil, ROP programs are fully integrated into the State and Municipal health systems, including those
developed with support of SiB. The ophthalmologists are recruited and employed by the health system,
and they receive a regular salary. This means that the programs are sustainable, and can be expanded
to other States and Municipal health services in Brazil. Lessons can be learnt by other countries in the
region and internationally as in many settings there are too few ophthalmologists willing to screen when
this is voluntary. The only way to expand coverage and provide sustainable programs of high quality is
for them to be fully integrated into the health system, as is the case in this project.
Educational materials;
The online educational materials have the potential to have a major impact on neonatal care in Brazil
and beyond.
Workshops:
The workshops in Latin America have evolved over time, responding to the emerging needs. Initial
workshops in the late 1990s and early 2000s focused on ophthalmologists and how they could be
trained and how they could set up and manage ROP programs. In subsequent workshops more
emphasis was put on prevention of ROP, and so more neonatologists and nurses were invited to
participate. As countries move towards the stage were legislation and support of Ministries of Health are
needed to improve coverage, representatives from health ministries and policy makers have been
invited. A similar evolution may well be needed in countries in Asia, such as The Philippines and
Indonesia where ROP control programs are in their infancy.
Lessons learned will contribute to extend capability for new projects in the field?
Comment on management of this project:
This project was managed by Dr Andrea Zin (50% time) with support by Cynthia Magluta (10%, IFF) and
a Finance Administrator (20%)(see Appendix 6). The CBM office helped with all financial issues at the
central level as well as with financial reporting. CBM also helped with the budget for the Cartagena
workshop
Highly complex projects such as this, which had multiple elements, partners and activities, require a full
time management team comprising full time experts in program and financial management, with input
from those with expertise in eye care and neonatal care. The amount of work this project entailed was
far too much for such a small team, which meant that Dr Zin worked way beyond what she was
supported to do. Ideally Dr Zin should have provided technical advice to a full time, experienced
Program Manager, supported by a full time Administrator, as a minimum.
Has the project significantly contributed to capacity strengthening?
Yes. All elements of the project focus on building the capacity of staff involved in neonatal care and ROP
programs. New staff have been trained to detect and treat sight threatening ROP; an educational
package has been developed and further national and regional workshops have been held.
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Workshops:
One of the purposes of the workshops is to build skills in needs assessment and planning, and to build
capacity in areas such as guideline development. Most of those attending the workshops are clinicians
who have not previously been exposed to the public health elements of ROP programs.
No other region has national or regional level workshops on ROP, and much can be learnt from the
experience in Latin America in other regions, such as Eastern Europe and South East Asia. Although it
is difficult to quantify the impact the workshops have had, they have undoubtedly contributed to the
development of ROP programs in Brazil and Latin and Central America, which were almost non-existent
in the late 1990s. The workshops and visits supported by SCB build on the awareness created since the
first workshop in Chile in 1997 when only two ophthalmologists in the whole region were screening for
ROP.
Is the project sustainable and potentially apt for scaling up?
Yes, the ROP programs in Rio are completely sustainable, and so can be scaled up within the Sate and
Municipal health systems.
How could international network be improved? Is there potential for wider knowledge sharing / capacity
strengthening within region and beyond?
The workshops provide an ideal opportunity for networking, sharing knowledge and experiences.
Facilitators at workshops could transfer their skills and use their experiences to develop workshops in
other regions. Indeed, workshops have already been held in Eastern Europe and workshops are planned
for Indonesia and the Philippines.
The 4th World Congress of ROP is due to be held in Mexico in 2014, providing an opportunity to share
experiences from this project to a very wide audience.
Provide 3-5 best practices that can be taken from the project.
1. Advocacy with Ministries of health, which led to ROP programs being fully integrated and
sustainable.
2. Excellent clinical training and support: Providing high quality ROP programs requires motivated
and committed ophthalmologists who are exposed to extensive, hands-on practical clinical
training by ophthalmologists experienced in examining and treating preterm infants. They also
need to be trained in how to set up, run and manage a program, as in this project. The ongoing
support, supervision, mentoring and problem solving by the trainers in this project is also a model
of best practice, maintaining quality as well commitment.
3. Health management information systems for ROP that are integrated into government systems
are likely to be used more regularly and have more an impact than stand alone ROP monitoring
systems.
4. National and regional multi-disciplinary workshops provide a mechanism for advocacy, planning,
networking, team building, sharing knowledge and problem solving. Other regions would benefit
17
enormously from the experiences in Latin America, where Andrea Zin has played a very major
role, supported by regional and international facilitators and experts.
5. The online educational materials provide a means of reaching a very large audience at little cost
to the end user.
Provide 3-5 recommendations for project in moving forward.
ROP programs:
1. An on-line library of images of ROP and its treatment would provide a useful resource during and
after training. The images could also be used for to create awareness amongst other staff and
parents. The library could include annotated images of the following: different stages of ROP
(typical and atypical presentations), what adequate laser treatment looks like, when and how to
retreat infants etc.
2. A network of the ophthalmologists be developed using social media (e.g. Facebook) to provide a
mechanism for sharing experiences and knowledge, to discuss new developments in diagnosis
and treatment; to design and undertake simple research studies and to disseminate relevant
publications for discussion.
3. Monitoring of the ROP programs could be improved, and standard data forms and registers
would assist in this. Monitoring should include coverage, the number of infants examined and
treated, by birthweight group, follow up rates, and rates of regression after treatment.
4. Awareness of the risk and consequences of ROP needs to be raised amongst parents so they
realize the importance of eye examinations, particularly after their infant has left the NICU. State
and Municipal health systems need to work with neontaologists, nurses and ophthalmologists to
improve communication with parents. Every opportunity should be taken to talk to parents by all
members of the team, supported by written information that is simple and clear, as many mothers
are extremely young, unmarried, and not well educated. Neonatologists should take the
responsibility for communicating to parents/carers at the time of discharge if the child needs
follow up eye examinations.
5. Advocacy with the State Ministry of Health is needed to improve the long term follow up of
preterm infants to detect and manage other ocular morbidity associated with preterm birth and
ROP (i.e. high myopia and other refractive errors, strabismus, cortical visual impairment and
visual perceptions problems). The State system provides this service but not the Municipal
system.
7. Educational materials:
The online course should be translated into Spanish, for use other countries in Latin America,
and English, for other regions (with translation, as required).
18
Part E: Context analysis
1. Has the situation in the country changed since the project's inception (particularly: new risks)?
Were certain issues either over- or under-estimated?
The State and Municipal systems are both restructuring, with closure of some units, and the
development of new units. The reason is to concentrate expertise, and to improve the link between
maternal health and neonatal care. These are very positive developments.
The State system is embracing public-private partnerships, with the staff in State facilities being
employed and managed by private companies. Salaries have been increased, and management has
improved.
Advocacy with the State Ministry of health took longer than anticipated which delayed the appointment
and training of ophthalmologists in the State system. This meant that the target number of preterm
infants to be examined (30%) could was only reached by early 2013.
Two of the six ophthalmologists identified for training are not running programs. One has taken on a
leadership role in his Eye Department, and the other ophthalmologist did not attend for training. Reasons
are not known.
Change in leadership in the neonatal units led to some lack of continuity.
Were initial project assumptions correctly assessed by project team?
The original intention had been that ROP programs would be developed in Sao Paulo, the assumption
being that there was willingness and commitment. However, it became clear after a year that little could
be achieved, and so the project was relocated to Rio. This was another cause of delay.
2. Provide an assessment of the project activities & project partner's relationship with others
who are active in the field.
Define areas of cooperation and coordination. Describe any problems?
Some neonatologists were not very supportive of the new ROP programmes to begin with; for example,
they did not allocate a nurse to assist the ophthalmologist. However, this changed over time as they
came to appreciate what the ophthalmologists were doing.
There was surprisingly little communication or co-ordination between the Municipal and State health
systems. Dr Zin has developed very good working relations with both, and provided a mechanism where
each could hear about the positive elements in the other.
CBM have supported ROP programs in Brazil in the past, and were the implementing partner for this
project. No other NGOs support ROP programs in Brazil.
19
3. In the project proposal, was the strategy clearly defined and appropriate?
Was the appropriate target population identified?
Yes
Was the strategy appropriately defined at the time of project inception?
Yes
4. In the project proposal, were the strategy and methodology clearly defined and appropriate?
Was the methodology appropriately defined at the time of project inception in terms of timing,
responsibilities, etc.?
Yes, but a change of site from Sao Paulo to Rio meant that there was a change in partners as well as
timing.
5. Milestones and achievements
Have the milestones so far been achieved and are on track? If not, please assess why.
1. Increased coverage of effective programs for detecting and treating ROP, with establishment
of programs beyond the city of Rio.
The target was to implement ROP screening and treatment program in 6 NICUs from State
government and 1 Municipal. One State NICU withdrew due to administrative problems.
Although 2 ophthalmologists were trained, they left the program and for this reason 2 State
units still do not have the program in place. The State government is looking for suitable
candidates to replace the professionals that left. The program is now being implemented 9 of
of the 11 NICUs of the project.
2. Management Information system for ROP developed and integrated into the State
government system. The Municipal government is considering the best way to incorporate
ROP into their MIS.
3. Six workshops (national and regional) were held, to disseminate best practice and for
planning and improving programs in Latin America, and 2 countries in the region were visited.
One country was not visited due to security issues (Honduras)
4. Educational materials on best practices for neonatal care and for the prevention, detection
and treatment of ROP for staff caring for preterm infants was developed and disseminated
through a web based course.
6. Impact and outcome measures
What outputs/measurable indicators have been achieved over the project's lifetime?
ROP programmes were extended outside the city of Rio
A further 30% of preterm infants are now in units with ROP programs
20
The system for monitoring ROP is embedded the Municipal governments HMIS for intensive
system. The State system is considering adopting a integrated system of monitoring
A online educational systems on neonatal care is available in Portuguese and the first course has
started
National and regional workshops took place as planned.
What expected outputs have not been achieved, and is it reasonable that they have not been?
Country visits were not undertaken by Dr Zin, for security reasons. Another country was not
selected because of competing demands
What impact has been seen with the achievements so far?
Assessing the impact of programs where the focus is prevention can be very challenging, requiring
baseline data, and clear indications that any inputs and outcomes have directly led to the impacts.
In Rio there was no base line data on the number of infants become ROP blind each year, as there is no
system for surveillance. After discussion with Dr Zin it became clear that this would be very challenging
to set up in Rio, as there is no tertiary referral eye department where infants with advanced ROP (Stages
4 and 5) are assessed or operated upon. Indeed, there is no vitreo-retinal surgeon in the city who
operates on Stage 4 ROP (Stage 5 being considered inoperable by most experts). In addition, infants
who are blind from ROP may have other disabilities, and so not be captured in data for children enrolled
in inclusive education. There is only one school for the blind in Rio, which only caters for blind children
who have no other impairment, and so data from this source are likely to be biased and under-estimate
the magnitude of the problem.
What can be said with certainty is that at least 25% of the infants treated for ROP during this project
would have become totally blind without treatment, and more infants would have become visually
impaired.
7. Reducing global inequities
What have been the project's activities and achievements in reducing gender disparities, either in terms
of education of girls or advancement of women?
There are no gender differences in the rates or severity of ROP, and all infants were examined
regardless of gender. There are no gender differences in access to NICUs.
What impact has the project had on improving the situation for the most disadvantaged in society?
This project was undertaken in the government health system, which caters for the poor. There are a
large number of private NICUs in the city, but these were not included in the program. Teenage
pregnancy and low socio-economic status are known to increase the risk of preterm birth, and a high
proportion on mothers of the babies examined in this project were very young and uneducated.
21
Having a blind child puts considerable strain on parents and families in terms of psychological, emotional
and economic impacts. As a result of this project infants have been prevented from becoming blind or
visually impaired from ROP, so avoiding further disadvantage.
8. Resource management
In terms of human resources, were clear roles and responsibilities defined and utilized for project staff?
Have any changes been made throughout the project?
After the project moved from São Paulo to Rio de Janeiro, a new staff had to be appointed.
Responsibilities and roles were clearly established.
Project staff:
Coordination/Management: Andrea Zin, Cynthia Magluta, Regina Fialho
Nurse trainers: Margareth Dutra, Edneia Oliveira, Marcelle Campos
Ophthalmology Training: Andrea Zin and Viviane Lanzelotte
Development of elearning resource Andrea Zin, Cynthia Magluta, Edneia Oliveira, Marcelle
Campos, Margareth Dutra, Olga Bonfim, Jose Roberto
Ramos, Maria Elizabeth Moreira, Maria de Fatima Junqueira
Marinho and Daniela Verzoni withinput from experts from the
University of Sao Paulo
In terms of infrastructure, has the project equipment been appropriately allocated and adapted for the
context? Are there any discrepancies from the original plan?
The only equipment provided was for examining babies, so that each NICU has its own, and one laser,
which is being shared by several ophthalmologists.
9. Sustainability & scale-up
How likely is this project to be sustained? Have activities already been or are being carried out with
regards to replication or scale up?
The ROP programs are highly sustainable as they are integrated into the health systems.
The ROP programs will continue after funding from this project ceases, and are likely to expand.
10. Monitoring and dissemination
What monitoring tools are being used and who is in charge of these? Were they appropriate?
Ophthalmologists were asked to report to Dr Zin every six months on the number of babies examined,
the number treated and their characteristics. These were appropriate indicators. As indicated above,
other indicators such as coverage, follow up rates and response to treatment would allow problems
needing action to be identified.
22
What activities have been undertaken to disseminate knowledge gained by the project – please provide
a quantitative and qualitative report on publications, presentations or other dissemination activities/tools.
The activities undertaken and preliminary results of the project have been presented in several meetings
organised for the Municipal and State Health Departments (2 meetings/year/Health Department),
meetings of the Brazilian Neonatal Research Network (2011 and 2012), one National ROP workshop
(Peru, Aug 2012), one Regional ROP workshop (Colombia, September 2013) and at the Standard
Chartered Bank office in New York City (October 2012).
23
APPENDIX 1. Map of Project area
Cities included in ROP programs:
Duque de Caxias, Nilópolis and Niterói (program could not be established)
Population in 2011
Whole state of Rio de Janeiro 16,112,678 100%
Metropolitan region Rio de Janeiro 11,909,897 74%
Cities outside Rio Metropolitan region 4,202,781 26%
Units in the SiB project are responsible for approximately 30% (450/1,500) of preterm babies born
annually in the Metropolitan with birth weights <1,500 eligible who require examination for ROP.
APPENDIX 2. MONITORING ROP PROGRAMS
Flow chart – see next page
24
Responsibility
Live Register Neonatologist/nurse
ROP Diary Nurse to maintain ROP diary
Completed by neonatal
ROP nurse
Nurse identifies babies for examination;
ROP Register Nurse dilate pupils;
Nurse assisits ophthalmologist during exam
Ophthalmologist to examine
Ophthalmologist to record findings
ROP Register Ophthalmologist to make management decision
Ophthalmologist Ophthalmologist communicate findings to parents/neonatology team
Neonatology team: at discharge, tell parents if follow up needed and date
ROP Register
Ophthalmologist
n
Ophthalmologist to treat
Ophthalmologist to record findings
Ophthalmologist to examine
Ophthalmologist to record findingsN= N=
At request of neonatologist N=
Stage of ROP
At each examination
When next exam needed
Did not develop disease needing
treatment
Developed disease needing
treatment
N =
N =
Yes
N =
Died before 4-6 weeks
Could not be contacted
Contacted but did not come
Other
Died
Completed by secretary
on admission
Transferred into NICU for
treatment
Stage 4 or 5 Regresssed
Treated
N =
Not treated N= Yes N=
Method of treamentReasons:
Inborn infants or very early transfer for
neonatal care
Transferred into NICU for
examination
Could not be contactedCompleted all eye examinations
Transferred out before
4-6 weeks
N = N =
Total eligible N=
Eligible for examination:
BW and GA criteria N=
Survived to 4-6 weeks
Not examined. Name not entered
in the in diary
Examined at 4-6 weeks, in NICU
or after dischargeOphthalmologist
N =
Reasons:
No (Failed, "F")
N =
N =
Other
Not examined. Name was in the diary
but not examined
N =
Reasons:
25
MONITORING ROP PROGRAMMES
EXCLUDE babies transferrred to the NICU just for ROP treatment
Name of NICU
Name of examining ophthalmologist(s)
Reporting period Year
Note: Report for the period ending 6 months earlier
Months to
Number of babies eligible for examination A
(from Live Register)
Extras added by neonatologist B
TOTAL who should have been examined C = A + B
Number and proportion of babies having first eye examination D % (D/C x100)
(from ROP Register)
Number and proportion of babies who should have had a first examination but did not: E (C-D) % (E/Cx100)
Number and proportion of babies completing ALL examination F % (F/C x100)
Number and proportion of babies NOT completing all examinations G (C-F) % (C/F x100)
Reasons: Died
Could not be contacted
Contacted but did not come
Other
Total admitted in
reporting period
Died/transferred
before 1st exam
Survived to date of
1st exam
26
Stages of ROP by birthweight group (maximum stage of ROP in worst eye at only/last examination)
No ROP No ROP Stage 1 Stage 2 Stage 3 Stage 4 Stage 5 AP-ROP
Fully vasc Immature vs
<1000gs
1000-1499
1500-1749
1750-1999
2000 or more
Stages of ROP by gestational age (maximum stage of ROP in worst eye at only/last examination)
No ROP No ROP Stage 1 Stage 2 Stage 3 Stage 4 Stage 5 AP-ROP
<26 weeks Fully vasc Immature vs
26-28
>28-30
>30-32
>32-34
>34
Number of babies treated in study period: inborn AP-ROP ET-ROP TOTAL
Note: exclude infants referred from other units just for ROP treatment :
Birthweight & gestational age of treated babies
Baby 1 PMA** wks BW GA Yes No
Baby 2 PMA** wks BW GA Yes No
Baby 2 PMA** wks BW GA Yes No
Baby 3 PMA** wks BW GA Yes No
Baby 4 PMA** wks BW GA Yes No
Baby 5 PMA** wks BW GA Yes No
Baby 6 PMA** wks BW GA Yes No
Baby 7 PMA** wks BW GA Yes No
Baby 8 PMA** wks BW GA Yes No
Baby 8 PMA** wks BW GA Yes No
Baby 10 PMA** wks BW GA Yes No
**PMA=post menstrual age at treatment
RegresssedMethod of treatmentCharacteristics of babies
27
Stages of ROP by birthweight group (maximum stage of ROP in worst eye at only/last examination)
No ROP No ROP Stage 1 Stage 2
Fully
vascularized
Immature
vessels
<1000gs
1000-1499
1500-1749
1750-1999
2000 or more
Stages of ROP by gestational age (maximum stage of ROP in worst eye at only/last examination)
No ROP No ROP Stage 1 Stage 2
Fully
vascularized
Immature
vessels<26 weeks
26-28
>28-30
>30-32
>32-34
>34
Number of babies needing treatment in study period: inborn AP-ROP ET-ROP TOTAL
Number of babies actually treated in study period: inborn AP-ROP ET-ROP TOTAL
Note: exclude infants referred just for ROP treatment :
Birthweight & gestational age of treated babies
Method used
Baby 1 PMA** wks BW GA Yes No
Baby 2 PMA** wks BW GA Yes No
Baby 2 PMA** wks BW GA Yes No
Baby 3 PMA** wks BW GA Yes No
Baby 4 PMA** wks BW GA Yes No
Baby 5 PMA** wks BW GA Yes No
Baby 6 PMA** wks BW GA Yes No
Baby 7 PMA** wks BW GA Yes No
Baby 8 PMA** wks BW GA Yes No
Baby 8 PMA** wks BW GA Yes No
Baby 10 PMA** wks BW GA Yes No
**PMA=post menstrual age at treatment
Characteristics of babies Regresssed
Stage 4a/b
Stage 4a/bStage 3
Stage 3
Stage 5
Stage 5 AP-ROP
AP-ROP
Do NOT include in
Stage 2 or 3
Do NOT include in
Stage 2 or 3
28
Data to be collected to register babies eligible for eye examination at the time of admission (“Live register”)
Mothers name Date
admitted Date of
birth
Inborn or referral
(outborn) Birthweight
Gestational age
Date when will be 4
weeks of age
Still in NICU at 4 weeks (Yes/No)
If not, why not: died,
transferred; discharged
1 2 3 4 5 6 7 8 9 10 etc
29
APPENDIX 3. WORKSHOP UNDERTAKEN DURING PROJECT PERIOD
Workshops 1. Target: To organize 6 workshops in 3 years (Venezuela, Mexico, Brazil, Peru, Nicaragua and
Colombia) 2. Output: 6 workshops organized from 2010-1013. Brazil workshop was cancelled due to local
management difficulties. El Salvador workshop was performed Country visits:
1. Target: To perform 3 visits: Honduras (year 1) and El Salvador (year 2), other (year 3) 2. Output: 2 visits were performed - El Salvador and Argentina. Honduras was cancelled due to
local management difficulties and Argentina was chosen because of a successful neonatal country intervention.
2010 Workshops: Colombia: October 20-23, 2010. Nicaragua: November 15-17, 2010. Visit: Guatemala (not El Salvador) was visited in Nov 18-19, 2010 by Dr Brian Darlow 2011 Workshops: Venezuela: July 22-23 (Follow-up workshop + strategic planning) 18 ophthalmologists, 10 pediatricians, 5 nurses and 2 Low Vision experts from 11 states of the country attended this workshop. CBM and the Venezuelan Society of Ophthalmology supported this event. Facilitators:
Dr. Luz Gordillo, Ophthalmologist, ROP expert from Lima
Dr. Ana María Villanueva, pediatrician from Lima. El Salvador: Sept 1-2 (1
st national workshop – situation analysis)
Seventy-seven individuals representing 16 cities from across El Salvador attended the Workshop consisting in 13 ophthalmologists, 31 neonatologists/pediatricians, and 33 NICU nurses as well as representatives from the MOH and USAID. Also present were Dr. Marina Estela Avalos, Director of Health from the Ministry of Health and Dr Roberto Sanchez Ochoa , director of the maternity hospital. Facilitators:
Eduardo H.Bancalari, MD, Miller School of Medicine, University of Miami, USA
Graham Quinn MD, MSCE, The Children’s Hospital of Philadelphia, University of Pennsylvania School of Medicine, USA
Ana Quiroga, Escuela de Enfermería, Universidad Austral, Argentina
International observer: Luxme Hariharan, Resident Physician, University of Pennsylvania Mexico: Aug 31-Sept 2 (Advocacy meeting) 90 participants (50 ophthalmologists, 20 neonatologists and 20 nurses) attended this workshop, Facilitators:
Dr. Brian Darlow, neonatologist, Christchurch School of Medicine, New Zealand,
Dr. M de la Fuente, ophthalmologist Yucatán and others.
30
2012
Peru, Lima: August 8-10 Purpose: A follow-up workshop for strategic planning and to revise the national ROP guidelines 70 participants: 22 ophthalmologists, 20 neonatologists/ pediatricians, 18 registered nurses, 1 medical technician and 9 representatives from the health authorities, MINSA and EsSalud. Facilitators:
Prof. Clare Gilbert (International Centre for Eye Health (ICEH), London School of Hygiene and Tropical Medicine (LSHTM), United Kingdom);
Dr. Andrea Zin (Fernandes Figueira Institute, FIOCRUZ, Brazil, PAHO Collaborative Centre for thePreventionofChildhoodBlindness, CBM advisor for ChildhoodBlindness);
Prof. Brian Darlow (University of Otago, New Zealand);
Dr Karin Van Dijk (CBM, global advisor for low vision, Low vision specialist Netherlands). Conclusions: 1. Good collaboration between nurses, neonatologists, ophthalmologists and institutions; 2. ROP programs been set up in many centres outside of Lima; 3. Legislation which makes examination for ROP mandatory for ROP and which guarantees payment
to hospitals is having a significant impact; 4. Babies are still being referred with advanced ROP. Reasons need to explored and how best to
expand ROP programs and improve the quality of existing programs to prevent these cases; 5. Many NICUs still lack key items of equipment, mainly for oxygen delivery. There also inadequacies
in labour wards, intermediate care nurseries and operating theatres; 6. There is a lack of trained ophthalmologists to treat ROP and a lack of lasers in some centres; 7. Nurse-infant ratios are less than optimal in many centres; 8. Low vision services are being implemented, both in Lima and in the provinces, and there is a need
to network these services with neonatal follow-up facilities. Honduras: Cancelled because of local difficulties.
Argentina visited by Dr Luxme Hariharan, MD, MPH, Resident Physician, University of Pennsylvania.
Purpose: To explore the role UNICEF and others played in bringing about the improvement in neonatal care that has taken place in Argentina, and to evaluate the impact in terms of rates of blindness due to ROP. 2013 III Regional ROP Workshop Cartagena, Colombia, September 9-10 40 participants (neonatologists, nurses, ophthalmologists) 8 facilitators; 7 international observers from CBM, Orbis, PAHO, Clarity, FIOCRUZ Outputs:
1. Revised regional ROP guidelines for prevention of ROP, taking account of the findings of recent clinical trials on optimum oxygen saturation targets, and for examination and treatment of ROP, taking account of the controversial new treatment with Avastin.
2. Strategic plan for the region defined
31
APPENDIX 4. Agenda for the regional ROP workshop in Cartagena, Colombia
32
33
34
35
APPENDIX 5. eLEARNING RESOURCE FOR ROP
Internet screen print outs of the POINTS-ROP online course
http://neonatal.estacaodigitalsaude.org.br/aia/
Front page
Collaborating institutions logos
36
Page where DVD on ROP can be accessed
Page where DVD on nutrition can be accessed
37
Page where DVD on delivery and monitoring oxygen can be accessed
First page of reading material on control of infection
38
Pages 3 and 4 of the text on supportive care
Pages 3 and 4 of the text on delivery and monitoring oxygen
39
Pages 3 and 4 of the text on ROP
40
Poster illustrating the POINTS-ROP topics
41
APPENDIX 6. PROGRAM MANAGEMENT
Countries
Location of project elements
Implementing agencies/partners
Financial management
Finance Administrator
CBM and SEEING IS
BELIEVING
UNIFESP, Sao Paulo CERCIL, Lima
Project Manager
Andrea Zin (50%)
ICI, Rio
International experts in
ROP, neonatal care and
low vision
International Committee
SALUD; MINSA
National/regional workshops
VISION 2020 partners (PAHO,
ORBIS, CBM)
Lima and other cities
Ministries of Health
Regina Fialho (20%
ICI, Rio
Cynthia Magluta (10%)
IFF, Rio
Rosario Spinoza
CERCIL, Lima
Luz Gordillo
IDV, Lima
Andrea Zin
CBM
PERU
Technical Advisor (LV)
Karin van Dijk
CBM Co-worker
Cities in Brazil Lima and other cities
BRAZIL
Improving low vision care for children
Municipal and State
Liliana Ventura
FAV, Recife
governments
Technical Advisor (N)
IFF, Rio and MOH
Cynthia Magluta (10%)
Cities in Rio State
PERULATIN AMERICA
Improving neonatal care
Improving ROP programmes
BRAZIL
